Community Assessment for Public Health Emergency Response (CASPER)

After the Flint Water Crisis: May 1719, 2016

Flint, Michigan
Final Report: July 2016

Centers for Disease Control and Prevention

National Center for Environmental Health,
Division of Environmental Hazards and Health Effects
Health Studies Branch

Acknowledgements
We would like to acknowledge the following persons for their contributions, without which, this
endeavor would not have been possible.
Flint Community Resilience Group, Mental Health Workgroup, Data & Gap Analysis SubWorkgroup
Michigan Department of Health and Human Services
Kenyetta Jackson
Jody Lewis
Price Pullins
Genesee Health System
Patricia Reynolds
University of MichiganFlint
Vicki Johnson-Lawrence
Genesee County Health Department
Substance Abuse and Mental Health Services Administration
Jeffrey Coady
Centers for Disease Control and Prevention, Health Studies Branch
Tesfaye Bayleyegn
Sherry Burrer
Gamola Fortenberry
Reba Griffith
Ariana Hanchey
Zuha Jeddy
Stephanie Kieszak
Kristin Marks
Amy Schnall
Alice Wang
Amy Wolkin
Centers for Disease Control and Prevention, Lead Poisoning and Prevention Program
Mary Jean Brown
Interview Teams
Survey Respondents

Executive Summary
On April 25, 2014, the City of Flint, Michigan changed their municipal water supply source from
the Detroit-supplied Lake Huron water to the Flint River. The switch resulted in the corrosion of water
distribution pipes and leaching of lead and other contaminants into municipal drinking water. On
October 1, 2015, Genesee County Board of Commissioners and Genesee County Health Department
declared a public health emergency and advised residents of Flint, Michigan not to drink the municipal
water. On October 15, 2015, funding was authorized to switch the municipal water source back to
Detroit-supplied Lake Huron water. On January 10, 2016, The Michigan Department of Health and
Human Services (MDHHS) activated the Community Health Emergency Coordinating Center (CHECC)
to coordinates all state-level public health emergency response activities. On January 13, 2016, the
CHECC behavioral health team requested federal resources and technical assistance from the Substance
Abuse and Mental Health Services Administration (SAMHSA) Disaster Technical Assistance Center.
The behavioral health team immediately formed a partnership with Genesee Health System (GHS), the
local community mental health agency responsible for emergency behavioral health response, to help
support behavioral health initiatives for community recovery. Subsequently, the following emergency
activities were initiated through this partnership: activation of the Disaster Distress 24/7 hotline and a
community hotline for immediate disaster crisis counselling, offering of crisis counseling to community
members through GHS, provision of training on Psychological First Aid to staff and volunteers at GHS
and community service agencies, application and award of the SAMHSA Emergency Response Grant,
provision of $28 M in supplemental funds including $500,000 in emergency aid for crisis behavioral
health services from the State of Michigan, request for expansion of Medicaid for those affected,
expansion of the Head Start program, and creation of the Flint Community Resilience Group (FCRG).

On January 16, 2016, President Obama declared a state of emergency for the City of Flint and Genesee
County.
In addition to health effects from lead exposure, there were concerns about the behavioral health
consequences of the Flint Water Crisis (FWC) for Flint residents, such as anxiety, depression, and
substance abuse. The FCRG, Mental Health Workgroup, Data & Gap Analysis Sub-Workgroup,
comprised of members from the MDHHS, Genesee County Health Department, GHS, and the
University of MichiganFlint, requested technical assistance from Centers for Disease Control and
Prevention (CDC) to investigate behavioral health effects from the FWC. A formal request for
assistance for a Community Assessment for Public Health Emergency Response (CASPER) in the City
of Flint came from MDHHS on April 6, 2016.
To aid in the recovery efforts, a CASPER was conducted May 1719, 2016 within the City of
Flint, Michigan. Specifically, the CASPER was conducted to assess the following: 1) household- and
individual-level, self-reported behavioral health concerns; 2) household access to behavioral health
services, including substance abuse and mental health services, and perceived barriers to access; 3) selfreported physical health concerns; 4) water-related resource needs and barriers to resources; and 5)
communication with the affected community. CDC provided interview teams with a three-hour training
prior to conducting interviews over three days in the field. A total of 182 household interviews were
completed. A weighted cluster analysis was conducted to report the projected percent of households; for
all results the percentages in the text represent weighted percentages. The major findings of the survey
fall under the following categories:
Self-Reported Behavioral Health Concerns
Of households with one or more members aged 21 years or older (n = 179), 65.6% (95% CI
[57.8, 73.5]) reported at least one member within that age group had one or more behavioral health
concerns more than usual since October 2015, with 44.9% reporting at least one household member
5

needed behavioral health services. Of households with one or more members aged less than 21 years (n
= 81), 54.3% (95% CI [40.4, 68.2]) reported at least one member within that age group had one or more
behavioral health concern more than usual since October 2015, with 51.7% reporting at least one
household member needed behavioral health services. Of households needing services (n = 43), the
following barriers to seeking services were reported: 47.3% reported having a hard time trusting
providers, 29.7% said services were too expensive and 25.9% said they had no transportation.
Several behavioral health questions were used from the Behavioral Risk Factor Surveillance
System (BRFSS) and administered at an individual level to respondents aged 18 years or older on selfreported negative quality of life indicators. An increased prevalence of individuals who had 14 or more
days of poor physical health days, poor mental health days, or limited activity days within the past 30
days was reported for the City of Flint compared to the reported prevalence for the state of Michigan in
the 2014 BRFSS.
Self-Reported Physical Health Concerns
Of all households (n = 182), half (50.5%) reported at least one person believed their physical
health had been worsened by the FWC, and among those with a worsened health condition the most
commonly mentioned condition was skin rash or irritation (49.6%).
Water-Related Resources
Respondents reported using multiple sources for water (n = 182). A high percentage of
households reported currently using bottled water for drinking and cooking including use of bottled
water from distribution sites (75.0%), bottled water from store (51.6%), and bottled water from home
distributors (35.4%). Additionally, filtered tap water (41.1%) was also used for drinking and cooking. Of
the 16.9% of households that reported having difficulty obtaining bottled, filtered, or well water, the
most commonly reported reason was no transportation (62.3%). Because of the FWC, many household
behaviors surrounding hygiene and water use have changed, including the following: reducing water
6

usage, decreasing the duration and frequency of showering/bathing, and changing the method of
showering/bathing (e.g., using baby wipes or hand sanitizer for washing).
Communication
Information on the FWC was most commonly received by households (n = 182) via television
(76.6%) and through neighbors, friends, or family (32.5%). The most trusted source of information was
news media (26.4%).
Based on these findings, FCRG could consider the following to guide the ongoing recovery
efforts in the City of Flint: focus resources on behavioral health intervention and follow-up surveillance
of behavior health concerns, consider economic costs to participants when implementing behavioral
health interventions, decrease dependence on bottled water by encouraging filtered tap water use in
order to return to normalcy, focus on less mobile populations (e.g., disabled, lack of transportation) in
terms of water and filter distribution, and increase community involvement and engagement in the
recovery phase of the FWC to assist with disseminating information on the FWC in City of Flint.

Background
On April 25, 2014, the City of Flint, Michigan changed their municipal water supply source from
the Detroit-supplied Lake Huron water to the Flint River (1). The switch in the water source resulted in
the corrosion of the water distribution pipes and leaching of lead and other contaminants into municipal
drinking water. Lead toxicity can affect every organ system and results in neurological, renal,
hematological, endocrine, gastrointestinal, cardiovascular, reproductive, and developmental effects,
including mental retardation and growth failure (2). In children, lead remains a common, preventable,
environmental health threat. Children are more susceptible than adults to the adverse effects of lead
exposure, due to hand-to-mouth actions, higher physiological uptake rates, and developing biological
7

systems (3). On September 24, 2015, results of a study were released by a Hurley Medical Center
researcher that demonstrated after the water source change, there was an increased incidence of elevated
blood-lead levels in children who were residents of Flint, Michigan (4). Subsequently, the City of Flint,
Michigan issued a lead advisory on September 25, 2015 that advised residents to use water only from
the cold water tap for drinking, cooking, and making baby formula (1). On October 1, 2015, Genesee
County Board of Commissioners and Genesee County Health Department declared a public health
emergency and advised residents of Flint, Michigan not to drink the municipal water useless it had been
filtered through a National Sanitation Foundation (NSF) approved filter certified to remove lead that
meets American National Standards Institute (ANSI) standard 53 (5). On October 15, 2015, funding was
authorized to switch the municipal water source back to Detroit-supplied Lake Huron water (1). On
January 16, 2016, President Obama declared a state of emergency for the City of Flint and Genesee
County (1). In addition to health effects from lead exposure, there were concerns about the behavioral
health consequences of the Flint Water Crisis (FWC) for Flint residents.
On January 10, 2016, The Michigan Department of Health and Human Services (MDHHS)
activated the Community Health Emergency Coordinating Center (CHECC) to support Flint Water
Crisis response efforts. The CHECC coordinates all state-level public health emergency response
activities. On January 13, 2016, due to the unique challenges and behavioral health implications of the
crisis, the CHECC behavioral health team requested federal resources and technical assistance from the
Substance Abuse and Mental Health Services Administration (SAMHSA) Disaster Technical Assistance
Center. The behavioral health team immediately formed a partnership with Genesee Health System
(GHS)the local community mental health agency responsible for a disaster and emergency behavioral
health response in Flintto help support strategic planning and funding of behavioral health initiatives
for community recovery. Subsequently, the following emergency activities were initiated through this
partnership:
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1) At the request of the CHECC behavioral health team, SAMHSA activated the Disaster Distress 24/7
hotline [January 15, 2016]. Additionally, GHS established a community hotline dedicated to providing
immediate disaster crisis counselling to assist distressed Flint residents affected by the water crisis.
2) GHS clinicians began offering crisis counseling to community members [January 23, 2016].
3) GHS and the CHECC behavioral health team provided training on Psychological First Aid (PFA)
and other rapid behavioral health prevention and intervention protocols to staff and volunteers at GHS
and community service agencies, such as Catholic Services [January 27, 2016]. These train-the-trainer
sessions were implemented to mitigate the immediate behavioral health needs of the Flint community.
4) On January 19, 2016, the SAMHSA Emergency Response Grant (SERG) application was
requested, and subsequently submitted on April 5, 2016. SAMHSA awarded the SERG to Michigan on
May 25, 2016.
5) The State of Michigan (SOM) provided $28 M in supplemental funds including $500,000 in
emergency aid for crisis behavioral health services [January 20, 2016]. The SOM also requested
expansion of Medicaid to provide health services to everyone 21 years and under affected by the water
crisis. This also expanded the availability of the Head Start program to provide enriched educational
environment for young children to help mitigate the effects of the emergency.
6)

In early February 2016, federal partners, GHS, and the CHECC behavioral health team established

the Flint Community Resilience Group (FCRG) to plan and mount a robust and coordinated behavioral
health response, inclusive of the whole community. The first full meeting of the FCRG was held on
February 2, 2016 and attended by 150 community partners. One of the first priorities identified by the
FCRG was to ensure the health and behavioral health services being initiated would meet the emerging
needs in Flint. After examining several needs assessment methods, the FCRG requested the CASPER.
On March 31, 2016, the FCRG, Mental Health Workgroup, Data & Gap Analysis SubWorkgroup, comprised of members from MDHHS, Genesee County Health Department, GHS, and the
9

University of MichiganFlint, contacted Centers for Disease Control and Prevention (CDC) to discuss
the use of a CASPER to investigate behavioral health effects from the FWC. A formal request for
assistance for a Community Assessment for Public Health Emergency Response (CASPER) in the City
of Flint, Michigan came from the MDHHS on April 6, 2016. On May 16, 2016, EIS Officers Gamola
Fortenberry and Alice Wang, and CDC staff Sherry Burrer and Amy Schnall departed for Flint,
Michigan. They provided technical assistance to the FCRG members in conducting a CASPER.
CASPER is an epidemiologic technique designed to provide household-based information about
a communitys needs in a timely, inexpensive, and representative manner (2). This information can be
used to initiate public health action, facilitate disaster planning, and assess new or changing needs
during the recovery period (6). The goals of this CASPER were to assess the following: 1) householdlevel, self-reported behavioral health concerns for adults (21 years and older) and children (under 21)
and individual-level, self-reported behavioral health concerns; 2) household access to behavioral health
services and perceived barriers to access; 3) self-reported physical health concerns; 4) water-related
resource needs and barriers to resources; and 5) communication with the affected community, including
receipt of FWC information, primary communication methods, trusted sources, and understanding of
English.

Materials and Methods

The FCRG Data & Gap Analysis Sub-Workgroup, with technical assistance from CDC,
conducted a CASPER in Flint, Michigan on May 1719, 2016. The FCRG Data & Gap Analysis SubWorkgroup, with consultation from CDC and other stakeholders, developed a two-page questionnaire
(Appendix A). The questionnaire included questions on household demographics; communications;
water sources and uses; household behavioral health concerns by Medicare healthcare coverage defined
age categories; household access and perceived barriers to behavioral health services; health care
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professional diagnosed chronic disease; self-reported physical health concerns worsened by the FWC;
and individual behavioral health concerns. MDHHS Institutional Review Board determined that this
CASPER was not research; therefore, it was exempt from human subjects review.
A two-stage cluster sampling methodology was used to select a representative sample of
households to be interviewed within the sampling frame (7). The sampling frame was defined as the
geographic city limits of Flint, Michigan (Appendix B), with a total of 24,983 housing units based on
updated housing data provided by the Flint City Planning and Development Office including households
regularly serviced by the municipal water supply system. First, 30 blocks (clusters) were selected with a
probability proportional to the number of housing units within the clusters from the predefined sampling
frame (Appendix B) using the Geographic Information Systems CASPER tool. Second, interview teams
used systematic random sampling to select seven households from each of the 30 selected clusters, for a
goal of 210 total interviews (30 clusters of 7 households each). Two-person interview teams were
assigned to two or three clusters, provided with detailed maps of their clusters, and instructed to go to
every nth household (where n is the total number of housing units in the cluster divided by seven) to
select the seven households per cluster to interview. Teams made three attempts at each selected
household before replacement of a household.
On Tuesday, May 17, 2016, CDC provided the interview teams with a three-hour just-in-time
training on the overall purpose of CASPER, household selection methods, questionnaire content,
interview techniques, safety, and logistics. There were a total of 11 teams on the first interview day, 12
on the second interview day, and 4 on the third interview day. All interview teams had at least one
person with public health and survey administration experience, and one person from the community.
Teams conducted interviews between 2:00 pm and 7:30 pm Eastern Standard Time. All potential
respondents approached were given a copy of the consent sheet containing contact telephone numbers
for Genesee Health System. Teams also provided public health informational materials regarding the
11

FWC (Appendix C), a rubber jar gripper, water bottle, stress ball, pen, pencil, and baby wipes to all
potential respondents and interested persons. Eligible respondents were 18 years of age or older and
resided in the selected household. At the completion of the interview, respondents were given a prestamped postcard to receive a $30 gift card to the Flint Farmers Market. Additionally, the interviewers
were instructed to complete confidential referral forms whenever they encountered urgent physical or
behavioral health needs.
We conducted weighted cluster analysis to report the projected number and percent of
households with a particular response in the sampling frame. Two weighting variables were calculated:
one to account for the probability that the responding household was selected and one to account for the
probability that the individual respondent within the household was selected. We weighted results
appropriately based on whether the question referred to the individual or to the household. Data analysis
was conducted in Statistical Analysis Software (SAS; version 9.3; SAS Institute Inc., Cary, NC) to
calculate the unweighted frequencies, unweighted percentages, weighted frequencies, and weighted
percentages with 95% confidence intervals. For all results, unless otherwise stated, the percentages in
the text represent weighted percentages.
Several questions regarding behavioral health were used from the national Behavioral Risk
Factor Surveillance System (BRFSS) and administered at an individual level to respondents who were
aged 18 years or older, present at the time that the household-level interview was conducted, and had an
upcoming birthday nearest to the date of interview. We compared quality of life questions to the
identical question in the 2014 BRFSS in Michigan. We took the depressive symptom questions from the
Patient Health Questionnaire-2 (PHQ-2) module in BRFSS and the anxiety questions from the
Generalized Anxiety Disorder-2 (GAD-2) module in a hospital-based Patient Health Questionnaire
study. Responses for the PHQ-2 and GAD-2 are scored from zero (not at all) to 3 (nearly every day),
and a combined score is calculated by adding the scores from the two questions within each module.
12

Total PHQ-2 scores of 3 have a sensitivity of approximately 80% and a specificity of approximately
90% for major depressive disorder (8); total GAD-2 scores of 3 have a sensitivity of 86% and a
specificity of 83% for generalized anxiety disorder, and a sensitivity of 65% and a specificity of 88% for
any anxiety disorder (9). It has been a decade since the PHQ-2 depressive symptom questions have been
asked as part of a BRFSS optional module in Michigan; we chose not to compare the PHQ-2 depressive
symptom questions data collected as part of this CASPER to BRFSS data collected 10 years ago. The
GAD-2 is not currently available in the BRFSS questionnaire, neither the core section nor the optional
modules; therefore, it has no population-based data available for comparison.

Results
Response Rates and Demographics
The interview teams conducted 182 interviews on May 1719, 2016, for a completion rate of
86.7% (Table 1). Teams completed interviews in 42.8% of the houses approached. However, excluding
vacancies (i.e., vacant lots and vacant homes), the contact rate was 52.8%. Of the households with an
eligible participant answering the door, 75.2% completed an interview. Table 2 shows the frequency and
weighted percentage of household demographics. Of the households, 93.4% lived in a single family
home and 66.2% owned their residence. The majority of households (88.3%) had one or more members
aged 2164 years, 20.4% of households had one or more children aged five years or younger, and 25.2%
of households had one or more members aged 65 years or older. Of the households, 4.5% had at least
one pregnant woman living in the home at the time of the interview. The average number of household
members is 3, with a minimum of 1 and maximum of 10 people living in a household.
For questions asked at the individual level, 182 individuals were interviewed. The majority of
respondents identified as black (57.7%) or white (42.9%), and non-Hispanic (97.6%) (Table 3). The
majority of individuals (79.5%) had lived in the community for greater than 12 years. The mean age of
13

respondents was 49.4 years and 69.0% of respondents were female.

Household Self-Reported Behavioral Health Concerns
Of all households, 65.6% (95% CI [57.8, 73.5]) reported that one or more household members
aged 21 years or older had at least one behavioral health concern more than usual since October 2015;
44.9% of these households perceived a need for behavioral health services. Among households with
members aged 21 years or older, many reported these members experiencing the following more than
usual: anxiety/stress (49.1%), problems sleeping (47.3%), depressed mood (42.6%), and trouble
concentrating (33.9%) (Table 4). Of these households with at least one household member under 21
years, 54.3% (95% CI [40.4, 68.2]) reported that one or more household members aged less than 21
years had at least one behavioral health concern more than usual since October 2015; 51.7% of these
households perceived a need for behavioral health services. Among households with members of this
age range, many reported these members experiencing the following more than usual: problems
sleeping (39.0%), aggressiveness (38.4%), trouble concentrating (37.5%), and anxiety or stress (35.3%)
(Table 5). The majority of households did not report increased use of substances (i.e., nicotine, alcohol,
illicit drugs, or off label use of prescription or over-the-counter drugs) since October 2015. However,
households reported at least one member increasing the use of nicotine products (e.g., cigarettes, ecigarettes, chewing tobacco) (23.7%), alcohol (13.6%), marijuana (10.1%), prescription or over-thecounter drugs used not as directed or not their own (4.3%), and other illicit drugs (1.1%) (Table 6).
Since April 2014, 26.4% of households reported a lot of stress related to compromised health
while 37.6% of households reported no stress related to compromised health due to FWC (Table 7). Half
(50.0%) of households reported a lot of stress related to feeling overlooked by decision-makers and also
feeling that the FWC will never be fixed. Many households (41.2%) experienced a lot of fear due to the
FWC in regard to drinking or cooking with filtered tap water while 57.9% experienced a lot of fear
drinking or cooking with unfiltered tap water (Table 8). Also, 22.6% of household felt some fear of
14

drinking or cooking with bottled water. The majority of households felt a lot of fear in bathing (55.2%)
and brushing their teeth (55.1%) with unfiltered tap water (Table 8).
Individual Self-Reported Behavioral Health Concerns
Twenty-nine percent of individuals self-reported depressive symptoms and 33.7% self-reported
symptoms of anxiety (Table 9). While 43.2% never or rarely worried or stressed about paying their rent
or mortgage, 22.6% reported being always or usually stressed or worried. In regards to buying nutritious
meals, 49.7% were never or rarely worried or stressed; however, 25.4% reported being always or
usually stressed or worried (Table 9). Approximately 37.0% of individuals living in the City of Flint
reported having a physical illness and/or injury for 14 or more days within the last 30 days, compared to
12.6% of 2014 Michigan BRFSS respondents representing the total population of Michigan (Table 10).
In the City of Flint, 38.0% of individuals reported having poor mental health (e.g., stress, depression,
and emotional problems) for 14 or more days within the last 30 days, compared to 12.9% for the total
population of Michigan as reported in the 2014 Michigan BRFSS. In the City of Flint, 29.1% of
individuals reported that poor physical and mental health limited their usual activities (e.g., self-care,
work, or recreation) for 14 or more days within the last 30 days, compared to 8.7% for the total
Michigan population as reported in the 2014 Michigan BRFSS (Table 10).
Household Access to Behavioral Health Services and Perceived Barriers to Access
Of those households with at least one member aged 21 years or older, 54.2% had members who
felt they did not need help, while 44.9% of members felt that they needed help with 21.6% of those
members seeking out help for behavioral health concerns from a counselor, pastor/clergy member,
therapist, or case/social worker (Table 4). Of the households with at least one household member under
age 21 years, 48.3% had members who felt they did not need help, while 51.7% of members felt that
they needed help. Of those households that needed behavioral health services for members aged less
than 21 years, 28.4% sought help from a counselor, pastor/clergy member, therapist, or case/social
15

worker (Table 5). Regardless of age, among the 22.5% (95% CI [15.5, 29.5]) of households reporting
difficulties seeking help, 47.3% had a hard time trusting in the healthcare system or health care
providers, 29.7% thought services were too expensive, 25.9% had no transportation, 13.4% were
disabled or homebound, 13.1% worried about what others would think, and 11.5% lacked health
insurance (Table 11).
Self-Reported Physical Health Concerns
When household respondents were asked if they or a member of their household had ever been
told by a healthcare professional that they had a selected list of chronic diseases, 38.6% reported
hypertension or heart disease; 32.3% reported physical disability, 31.7% reported asthma, chronic
obstructive pulmonary disease, or emphysema; and 31.7% reported diabetes (Table 12). Approximately
half (50.5%) of households reported worsened physical health of one or more members of a household
due to the FWC (Table 13). Among those households, the top physical health effects reported via openended responses included: skin rash or irritation (49.6%), hair loss (9.4%), and muscle aches or pain
(4.9%) (Table 13).
Water-Related Resource Needs and Barriers to Resources
Table 14 and Figure 1 show the frequency and weighted percentage of household responses
related to household water source for drinking and cooking. Before April 2014 (before the City of Flint,
Michigan changed their municipal water supply source from the Detroit-supplied Lake Huron water to
the Flint River), the top three household sources of water for cooking and drinking were unfiltered tap
water (78.2%), bottled water from the store (29.6%), and filtered tap water (7.5%). Between April 2014
and October 2015 (after the City of Flint, Michigan changed their municipal water supply source, but
before residents of Flint, Michigan were advised not to drink the municipal water), the top three
household sources of water for cooking and drinking were unfiltered tap water (59.3%), bottled water
from store (49.7%), and filtered tap water (12.3%). Though advised not to consume unfiltered municipal
16

tap water since October 1, 2015, of those households reporting unfiltered tap water use, 15.0% of
households reported use of unfiltered tap water for drinking and 20.2% of households reported use for
cooking after that time (Table 15). Also, since October 2015, the majority of households (82.7%) have
not faced barriers in obtaining bottled water, filtered water or well water (Table 16). Of the 16.9% of
households that faced barriers, the top three barriers reported were no transportation (62.3%),
distribution sites do not give out enough water (39.5%), and being disabled or homebound (25.4%).
In May 2016 (at the time of interview), the top three household sources of water for cooking and
drinking were bottled water from distribution sites (75.0%), bottled water from the store (51.6%), and
filtered tap water (41.1%) (Table 14, Figure 1). If using water filters for drinking and cooking, 91.4% of
household respondents reported having filters on the kitchen faucet, and 12.6% on the bathroom sink
(Table 17). When asked about specific behavioral changes, the majority of households interviewed
reported changing their behavior; 78.2% of households reduced water usage, 67.0% decreasing duration
of bathing/showering, 58.9% decreasing frequency of bathing/showering, and 58.1% changing
bathing/shower methods altogether (Table 18).
Communication with the Affected Community
The main types of information received by households interviewed regarding the FWC included
the following: lead in Flint water (92.0%), bottled water/filter distribution (89.7%), water filter use
instructions (80.0%), water testing resources (78.7%), and nutrition (57.1%) (Table 19). The main
sources of this information were television (76.6%), neighbor/friend/family (32.5%), social media
(27.1%), radio (24.1%), newspaper (20.7%), and publically available information fliers (21.5%) (Table
20). The main most trusted household sources of information about the FWC were news media (26.4%),
Genesee County Health Department (9.3%), health professionals (8.6%), faith-based organizations
(6.4%) and social media (5.1%) (Table 21). However, many respondents chose Other as their most
trusted source of information (24.9%). Of those reporting Other, their open-ended responses included
17

trusted self/did not trust anyone (31.1%), did not trust any of the listed sources (26.9%), and no trust in
government (9.9%). According to respondents, in 96.9% of households all members understood English
(Table 22).
Greatest Need for Households
When asked about the current greatest household need, the top three open-ended responses were
related to financial concerns (33.6%), safe water (27.5%), and plumbing/repair (14.7%) (Table 23). Of
those expressing financial concerns, 18.9% reported paying for utilities being of greatest concern.
Referral Needs
Interview teams submitted 8 referrals for additional needs or services directly to the local GHS
lead for the CASPER. Needs or services were categorized as the following: basic needs (i.e., food,
water and finances) (n=2), filter needs (n=2), furniture (n=2), lead resources (n=1), job placement (n=1),
and water delivery (n=1). Participants requesting services were referred to the GHS customer services,
GHS targeted case management, Flint Cares, and Michigan211.

Discussion
These results represent the community responses captured via the CASPER surveys conducted in
Flint, Michigan during the recovery phase of the FWC. Six topic areas formed the basis of this
CASPER: 1) demographics, 2) self-reported household physical health and behavioral health concerns
for adults (21 years and older) and children (under 21 years) related to the FWC, 3) self-reported
individual behavioral health concerns, 4) water sources and use, 5) difficulties obtaining water and
water-related resources, and 6) communications.
Demographics of the sampling frame (i.e., the geographic city limits of Flint, Michigan) were
similar to the most recent U.S. Census estimates, except for the frequency of female respondents
(69.0%) (10). According to the U.S. Census estimates for 2010, female persons represent 52.0% of the
18

Flint, Michigan population, which suggests that an oversampling of females occurred and the sample of
interviewed individuals may not be representative of the sampling frame. However, the City of Flint
population has steadily declined in recent years, which may have changed the demographic makeup
(10).
The majority of households had one or more of their members self-report worsening of their
physical health because of the FWC; skin rashes or irritations were the most cited physical health effect.
However, the association between lead exposure and skin rash or irritation is unclear, and MDHHS and
CDC are investigating these self-reported symptoms. Health effects such as fatigue, nausea,
forgetfulness, and muscle ache or pain were reported by households; these symptoms have previously
been associated with lead exposure (2). Some households also reported physical injury, including
muscle aches or joint pain, due to the repetitive motion of opening many bottles of water or lifting heavy
cases of water. This was typically noted in the households with elderly members.
At the household level, 51.7% of households perceived a need for behavioral health services for
one or more members younger than aged 21 years and 44.9% perceived a need for members aged 21
years or older. This need for services is supported at the individual level, including an increase in
prevalence of negative quality of life indicators. An increased prevalence of individuals had 14 or more
days of poor physical health days, poor mental health days, or limited activity days within the past 30
days compared to the reported prevalence for the state of Michigan in the 2014 BRFSS (11). In this
survey, respondents reported almost three times more physical and behavioral health concerns than
reported by the state of Michigan BRFSS. The percent of individuals reporting symptoms of depression
and anxiety is comparable or higher, respectively, than results from the 2010 Alabama Gulf Spill
CASPER (12). Due to the increased prevalence of negative quality of life indicators, depressive
symptoms, and symptoms of anxiety, additional recovery resources might be considered for behavioral
health intervention and follow-up surveillance of behavior health concerns. Because almost one-fourth
19

of households and individuals indicated worry or stress about finances, the economic cost of access to
behavioral health services might also be considered.
Of the households reporting use of unfiltered tap water after October 2015, 20.2% were still
using unfiltered tap water for cooking and 15.0% were still using it for drinking despite the public health
emergency declaration that advised residents of Flint not to drink the municipal water unless it had been
filtered. Though household respondents were not directly asked why they were still using the unfiltered
tap water, it is possible that they were experiencing one or more barriers to acquiring water other than
unfiltered tap. Of those who had difficulty obtaining water other than unfiltered Flint municipal tap
water, 62.3% did not have transportation and 25.4% were disabled or homebound. Despite efforts to
establish distribution sites around the city and visiting homes to distribute bottled water, from these
results, it is possible that certain less mobile household members were not reached; therefore, a focus on
less mobile populations is important. It could also be possible that there was minimized concern in the
community despite restrictions in municipal water consumption. Perceived risks of drinking tap water
might be low in areas where there are usually reliable water supplies (13). As of May 2016 when the
CASPER was conducted, residents of Flint had been advised since October 2015 not to drink unfiltered
municipal tap water, and households were relying mostly on bottled water for drinking and cooking
(14). Yet more than two thirds of households have at least one member who feels some or a lot of fear
using filtered tap water for drinking or cooking, and some households reported fear in using bottled
water for drinking or cooking. This may be due to continued distrust, stress, and anxiety that households
are reporting since the FWC took place. Encouraging the community to use filtered tap water is
important in decreasing dependence on bottled water in order to return to normalcy. Additional reasons
for encouraging use of filtered tap water use are: to decrease physical health complaints surrounding
opening water bottles and lifting heavy water cases, environmental reasons regarding increasing plastic

20

waste, and economic sustainability. In addition, fear and mistrust needs to be acknowledged in
messaging.
The main household source of information about the FWC was television, which is consistent
with a disaster or emergency that does not affect communication infrastructure. Gaining information
from neighbors, friends, or family was another common source of information. Similarly, media and
family/friends are typical sources of information about tap water reported when considering factors that
influence public perception on drinking water quality (13). Additionally, common information sources
during the FWC may reflect the communitys lack of trust with officials and reliance on themselves for
information. The most trusted source of information about the FWC was the news media (26.4%). Of
those who responded Other for trusted information resource, more than half (58.0%) of household
respondents reported in open-ended responses, trusting no one, only trusting themselves, or trusting
none of the listed sources. This percentage of distrust maybe be underestimated because the data were
gathered for Other using an open-ended format. Half of households had one or more members who
experienced a lot of stress because they felt overlooked by decision-makers and fear that the FWC
would never be fixed. Because households commonly use family and friends as a source of information
and the most trusted sources of information include local people and organizations (Genesee County
Health Department, health professionals, and faith-based organizations), increased community
involvement and engagement in the recovery phase of the FWC could assist in communicating
information in the City of Flint.

Conclusions
This CASPER was an initial step in assessing behavioral health needs of the community of Flint,
Michigan and establishing a baseline on 1) demographics, 2) self-reported household physical health and
behavioral health concerns for adults (21 years and older) and children (under 21 years) related to the
21

FWC, 3) self-reported individual behavioral health concerns, 4) water sources and use, 5) difficulties
obtaining water and water-related resources, and 6) communications.
Based on the results of this CASPER, FCRG could consider the following to guide the ongoing
recovery efforts in the City of Flint: focus resources on behavioral health interventions and follow-up
surveillance, repeat the CASPER in one year to follow-up on behavioral health concerns, consider the
impact of economic factors when implementing behavioral health interventions, decrease dependence on
bottled water by encouraging filtered tap water use, focus on less mobile populations in terms of water
and filter distribution, and increase community involvement and engagement in the recovery phase of
the FWC to assist with disseminating information on the FWC in City of Flint.

22

References
1. Dixon, Jennifer. Detroit Free Press. How Flint's water crisis unfolded. [Online] Detroit Free Press.
http://www.freep.com/pages/interactives/flint-water-crisis-timeline/

2. Agency for Toxic Substances & Disease Registry (ATSDR). Lead Toxicity: What are the physiologic
effects of lead exposure? [Online] August 20, 2007. [Cited: May 25, 2016.]
http://www.atsdr.cdc.gov/csem/csem.asp?csem=7.

3. Murata K, Iwata T, Dakeishi M, Karita K. Lead Toxicity: Does the Critical Level of Lead Resulting in
Adverse Effects Differ between Adults and Children? J Occup Health, 2009, Vol. 51, pp. 1-12.

4. Hanna-Attisha M, LaChance J, Sadler RC, Schnepp AC. Elevated Blood Lead Levels in Children
Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health
Response. American Journal of Public Health, 2016, 106 (2).

5. Genesee County Board of Commissioners. Public Health Emergency Declaration for People Using
the Flint City Water Supply with the Flint River as the Source. [Online]
http://www.gc4me.com/docs/public_health_emergency_announcement_10_1_15.pdf.

6. Malilay J, Flanders WD, Brogan D. A modified cluster-sampling method for post-disaster rapid
assessment of needs. Bulletin of the World Health Organization, 1996, 74 (4): 399-405.

7. Centers for Disease Control and Prevention (CDC). Community Assessment for Public Health
Emergency Response (CASPER) Toolkit: Second edition. Atlanta, Georgia: CDC, 2012.

8. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item
depression screener. Med Care. 2003 Nov; 41 (11): 1284-92.

9. Kroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care: prevalence,
impairment, comorbidity, and detection. Ann Intern Med, 2007; 146: 317-25.
23

10. United States Census Bureau. Flint City, Michigan Quick Facts from the US Census Bureau.
[Online] 2016. [Cited: June 3, 2016.]
http://www.census.gov/quickfacts/table/PST045215/2629000,00#flag-js-X.

11. Michigan Department of Health and Human Services (MDHHS). Statistics, Division of Vital
Records & Health. Deaths and Crude Death Rates for the Ten Leading Causes of Death, Michigan 2013
and United States Residents. [Online] 2012.
http://www.michigan.gov/documents/mdch/2014_MiBRFS_EP_Region_Tables_FINAL_500162_7.pdf

12. Centers for Disease Control and Prevention (CDC). Community Assessment for Public Health
Emergency Response (CASPER) after the Gulf Coast Oil Spill: Alabama, 2010. [Online]
https://www.adph.org/CEP/assets/CASPER_report.pdf.

13. Doria, M. de Franca. Factors influencing public perception of drinking water quality. Water Policy,
2010; Vol. 12: 1-19.

14. United States Environmental Protection Agency (USEPA). Flint Drinking Water Response. [Online]
2016. https://www.epa.gov/flint

24

Table 1. Questionnaire response rates for the 2016 Flint CASPER

Questionnaire response

Percent

Rate

Description

Completion1

86.7

Contact2

42.8

182
210

210

Contact (excluding vacancies) 2

52.8

Cooperation3

75.2

182
345

182
425
182
242

Percent of surveys completed in relation to the goal of 210

Percent of households randomly selected and completing an interview, vacancies (i.e., vacant lots and vacant houses) were
marked by interview teams
3
Percent of contacted households that were eligible and willing to participate in the survey
2

25

Table 2. Household (HH) demographic

Frequency

% of HH

Projected HH

Weighted %

Type of structure (n=182)

Single family
168
92.3
23327
Multiple unit
11
6.0
1299
Mobile home
1
0.5
119
Other1
2
1.1
238
Ownership of residence (n=182)
Own
120
65.9
16536
Rent
60
33.0
8224
Other2
2
1.1
223
Number (%) of households with members in each age category (n=182)
<5 years old
37
20.3
5090
6-17 years old
55
30.2
7501
18-20 years old
19
10.4
2622
21-64 years old
161
88.5
22071
>65 years old
44
24.2
6297
Household pregnant (n=182)
Yes
8
4.4
1136
No
174
95.6
23847
Number of people living in household
mean
median
min
Weighted
3.0
2.2
1
1
2

Weighted
95% CI

93.4
5.2
0.5
1.0

87.099.7
0.011.3
0.01.5
0.02.9

66.2
32.9
0.9

59.872.6
26.839.0
0.02.2

20.4
30.0
10.5
88.3
25.2

13.127.6
24.136.0
5.215.8
83.992.7
17.532.9

4.5
95.5

1.67.5
92.598.4

max
10

95% CI
2.73.3

Other types of structures mentioned included: townhouses (n=2)

Other ownership of residence mentioned included: Son owns the property, land contract

26

Table 3. Individual Demographics

Frequency

Weighted %

Weighted 95% CI

60
122

31.0
69.0

23.638.5
61.576.4

14
13
7
148

6.5
8.3
5.8
79.5

2.810.2
3.612.9
0.311.3
72.386.7

99
75
5
1
0

57.7
42.9
1.8
0.2
0.0

42.173.3
27.358.4
0.03.7
0.00.7
---

5
177

2.4
97.6

0.04.8
95.2100.0

Sex (n=182)
Male
Female
Time lived in City of Flint (n=182)
< 2 years
>27 years
812 years
>12 years
Race (n=172)1
Black or African American
White
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Hispanic or Latino (n=182)
Yes
No
Age of individual respondents

Weighted age statistics

1

mean

median

min

max

49.4

51.0

18

90

95% CI
(mean)
46.852.0

Multiple responses could be selected; some responses were missing (n = 1) or respondents refused (n = 9)

27

Table 4. Household self-reported behavioral health concerns for members aged 21 years or older
Frequency

% of HH

Behavioral Health: 21 years and older (n=179)1

Anxiety/stress
90
50.3
Problems sleeping
87
48.6
Depressed mood
77
43.0
Trouble concentrating
64
35.8
Emotional outbursts
58
32.4
Aggressiveness
55
30.7
Decreased appetite
55
30.7
None
58
32.4
2
Sought help (n=174)
Yes
40
23.0
No, but needed help
40
23.0
No, did not need help
93
53.4
1
2

Projected
HH

Weighted
%

Weighted
95% CI

12092
11644
10473
8336
7956
7254
7073
8095

49.1
47.3
42.6
33.9
32.3
29.5
28.7
32.9

41.856.5
39.155.5
33.451.7
25.842.0
23.641.1
21.237.8
20.736.8
25.240.6

5122
5544
12884

21.6
23.3
54.2

15.727.4
15.731.0
46.362.2

Multiple responses could be selected; Not applicable (n=3); Dont know (n=3)
Not applicable (n=8); Dont know (n=1)

Table 5. Household self-reported behavioral health concerns for members aged less than 21 years
Frequency

% of HH

Behavioral Health: Under 21 years (n=81)1

Problems sleeping
31
38.3
Aggressiveness
30
37.0
Trouble concentrating
30
37.0
Anxiety/stress
29
35.8
Problems in school
24
29.6
Depressed mood
24
29.6
Emotional outbursts
24
29.6
Decreased appetite
19
23.5
None
37
45.7
2
Sought help (n=81)
Yes
22
27.2
No, but needed help
19
23.5
No, did not need help
40
49.4
1
2

Projected
HH

Weighted %

Weighted
95% CI

4285
4222
4119
3883
3347
3236
3152
2598
4963

39.0
38.4
37.5
35.3
30.4
29.4
28.7
23.6
45.1

26.551.4
26.250.5
23.851.1
22.148.5
19.141.8
17.541.3
17.439.9
13.433.8
31.059.2

3134
2572
5321

28.4
23.3
48.3

16.540.4
11.135.6
35.161.4

Multiple responses could be selected; Not applicable (n=100); Dont know (n=1)
Not applicable (n=101)

28

Table 6. Household increased use of substances since October 2015

Nicotine (n=178)1
Alcohol (n=175)2
Marijuana (n=174)3
Other illicit drugs (n=172)4
Prescription or OTC drugs
not as directed or not your
own (n=171)5

25.3
14.9
10.9
1.2

Projected
HH
5810
3259
2429
258

Weighted
%
23.7
13.6
10.1
1.1

Weighted
95% CI
16.930.5
9.118.1
5.115.2
0.02.6

4.7

999

4.3

1.57.0

Frequency

% of HH

45
26
19
2
8

Nicotine products including: cigarettes, e-cigarettes, and chewing tobacco; Missing (n=4); Refused (n=2)
Missing (n=7); Refused (n=1)
3
Missing (n=8); Dont know (n=8); Refused (n=2)
4
Missing (n=10); Dont know (n=3); Refused (n=1)
5
Missing (n=11); Refused (n=2)
2

Table 7. Household stress due to the Flint water crisis

Frequency

% of
HH

Compromised health (n=181)1

None
66
36.5
Some
58
32.0
A lot
50
27.6
Financial worries (n=181)2
None
79
43.6
Some
37
20.4
A lot
62
34.3
3
Added stressors to daily routine (n=182)
None
55
30.2
Some
52
28.6
A lot
73
40.1
Feeling overlooked by decision makers (n=180)4
None
46
25.6
Some
38
21.1
A lot
92
51.1
Feeling that crisis will never be fixed (n=181)5
None
36
19.9
Some
46
25.4
A lot
92
50.8

Projected
HH

Weighted
%

Weighted
95% CI

9347
8009
6555

37.6
32.2
26.4

30.744.5
27.636.9
19.233.5

10983
5321
8179

44.2
21.4
32.9

36.052.4
14.728.1
25.440.4

7498
7450
9792

30.0
29.8
39.2

23.136.9
23.336.4
32.046.4

6461
5411
12387

26.1
21.9
50.0

18.134.1
14.129.6
41.858.3

5272
6197
12444

21.2
24.9
50.0

15.726.7
18.631.3
42.757.4

Missing (n=1); Dont know (n=6); Refused (n=1)

Missing (n=1); Dont know (n=2); Refused (n=1)
3
Dont know (n=1); Refused (n=1)
4
Missing (n=2); Dont know (n=3); Refused (n=1)
5
Missing (n=1); Dont know (n=6); Refused (n=1)
2

29

Table 8. Household fear due to the Flint water crisis

Frequency

% of HH

Drinking/cooking with filtered tap (n=182)1

None
53
29.1
Some
50
27.5
A lot
77
42.3
Drinking/cooking with bottled water (n=182)2
None
118
64.8
Some
42
23.1
A lot
21
11.5
Drinking/cooking with unfiltered tap (n=182)3
None
39
21.4
Some
34
18.7
A lot
107
58.8
4
Bathing w/unfiltered tap (n=182)
None
39
21.4
Some
40
22.0
A lot
100
54.9
Brushing teeth w/unfiltered tap (n=181)5
None
44
24.3
Some
34
18.8
A lot
101
55.8

Projected HH

Weighted %

Weighted
95% CI

7862
6574
10304

31.5
26.3
41.2

25.038.0
20.632.0
33.748.8

16393
5650
2836

65.6
22.6
11.4

57.673.6
15.429.8
6.716.0

5363
4854
14453

21.5
19.4
57.9

15.027.9
12.925.9
50.665.1

5786
5023
13784

23.2
20.1
55.2

15.930.4
13.9-26.3
47.962.4

6778
4168
13710

27.2
16.8
55.1

18.835.7
11.122.4
48.661.6

Dont know (n=2)

Dont know (n=1)
3
Dont know (n=2)
4
Dont know (n=3)
5
Missing (n=1); Dont know (n=2)
2

30

Table 9. Self-reported individual behavioral health concerns

Frequency

Weighted %

Depression (n=182)
Yes
29.6
57
No
70.4
125
Anxiety (n=182)
Yes
33.7
62
No
66.3
120
1
Worried or stressed about paying rent/mortgage (n=179)
Never/Rarely
43.2
87
Sometimes
34.1
52
Always/Usually

22.6
40
Worried or stressed about buying nutritious meals (n=180)2
Never/Rarely
49.7
96
Sometimes
24.9
40
Always/Usually
25.4
44
1
2

Weighted
95% CI
21.238.0
62.078.8
25.541.8
58.274.5
34.352.2
25.742.5
14.730.6
39.160.3
16.932.9
15.735.2

Missing (n=3)
Missing (n=2)

Table 10. Self-reported individual behavioral health concerns of respondents and 2014 Michigan
Behavioral Risk Factor Surveillance System (BRFSS) comparison

Frequency

Weighted %

Weighted 95%
CI

Physical illness and injury during the past 30 days (n=178)2

<13 days
113
63.0
52.573.4
>14 days
65
37.0
26.647.5
3
Poor mental health during the past 30 days (n=176)
<13 days
111
62.0
55.668.4
>14 days
65
38..0
31.644.4
Interruption of normal activities during the past 30 days (n=180)4
<13 days
128
70.9
62.779.2
>14 days
52
29.1
20.837.3

Michigan BRFSS 2014

Weighted %
(95% CI)1
--12.6 (11.8-13.6)
--12.9 (11.9-14.0)
--8.7 (8.0-9.6)

BRFSS asked respondents if experienced health indicator on at least 14 days in the past month
Missing (n=4)
3
Missing (n=6)
4
Missing (n=2)
2

31

Table 11. Household difficulties in seeking services for behavioral health concerns
Frequency
Difficulties in seeking help (n=43)1
Hard time trusting in providers
Too expensive
No transportation
Disabled/homebound
Worried what others will think
No health insurance
Goes against beliefs
Not aware of resources
No child care
Language barriers
Other2

20
12
12
5
6
5
3
2
1
1
3

% of
HH

Projected
HH

Weighted %

Weighted 95%
CI

46.5
27.9
27.9
11.6
14.0
11.6
7.0
4.3
2.3
2.3
7.0

2754
1728
1507
778
761
669
357
238
119
119
357

47.3
29.7
25.9
13.4
13.1
11.5
6.1
3.9
2.0
2.0
6.1

29.764.9
16.742.6
12.539.3
0.029.0
0.725.5
1.221.7
0.013.0
0.09.5
0.06.3
0.06.1
0.013.0

139 of respondents either had no difficulties seeking help (n=115) or no need for services (n=24); Missing (n=3)
Multiple responses could be selected; Other difficulties included: need to hire advocate for children, provider believes no
problems and denied care, refused help
2

Table 12. Household chronic health conditions diagnosed by a healthcare professional

Frequency
Asthma/COPD/Emphysema (n=182)1
Diabetes (n=182)2
Developmental Disability (n=181)3
Hypertension/Heart Disease (n=182)4
Physical Disability (n=182)
Psychosocial/Mental Illness (n=181)5

58
55
18
66
59
36

% of
HH
31.9
30.2
9.9
36.3
32.4
19.9

Projected
HH
7921
7913
2427
9643
8062
4673

Weighted
%
31.7
31.7
9.8
38.6
32.3
18.8

Weighted 95%
CI
23.539.9
25.338.1
5.014.5
28.748.5
24.540.0
12.525.1

Dont know (n=2)

Dont know (n=2)
3
Missing (n=1); Dont know (n=4)
4
Dont know (n=3)
5
Missing (n=1); Dont know (n=2), Refused (n=2)
2

32

Table 13. Self-reported worsening of physical health due to the Flint water crisis reported by one or more
household members
Frequency

% of HH

Physical Health Worsened by FWC (n=182) 1

Yes
93
51.1
No
69
37.9
2
Specified Health Effects (n=93)
Skin rash/irritation
46
49.5
Hair loss
9
9.7
Muscle aches/pain
4
4.3
Fatigue
4
4.3
3
Other
41
44.1

Projected HH

Weighted %

Weighted 95%
CI

12613
9446

50.5
37.8

43.457.5
29.745.9

6256
1185
619
481
5437

49.6
9.4
4.9
3.8
43.1

37.9-61.3
1.8-17.0
0.0-13.1
0.1-7.5
30.4-55.8

Dont know (n=20)

Categorized open-ended responses; Multiple responses could be selected
3
Other includes: low immune system, Chrohns Disease, lupus flair up, mental illness, nausea, forgetfulness, weight, cancer,
Kawasaki disease, Scarlet Fever, liver enzymes up, nodules on thyroid
2

33

Table 14. Household water sources for drinking and cooking in Flint, Michigan
Frequency

% of HH

Projected HH

Water sources before April 2014 (n=182)

Unfiltered tap water
144
79.1
19548
Bottled water from store
52
28.6
7407
Filtered tap water
12
6.6
1867
Well water
0
0.0
0
1
Other
7
3.8
913
Water sources between April 2014 and October 2015 (n=182)
Unfiltered tap water
109
59.9
14808
Bottled water from store
88
48.4
12411
Filtered tap water
22
12.1
3082
Well water
1
0.5
167
Other2
6
3.3
684
Current Water sources (n=182)
Distribution site
135
74.2
18730
Bottled water from store
96
52.7
12883
Filtered tap water
71
39.0
10265
Home distributors
62
34.1
8839
Unfiltered tap water
4
2.2
476
Well water
0
0.0
0
Other3
6
3.3
732

Weighted %

Weighted
95% CI

78.2
29.6
7.5
0.0
3.7

71.7 84.8
21.138.2
3.3 11.6
--1.1 6.2

59.3
49.7
12.3
0.7
2.7

51.9 66.7
41.2 58.1
7.4 17.3
0.0 2.0
0.3 5.2

75.0
51.6
41.1
35.4
1.9
0.0
2.9

64.485.5
40.362.8
30.152.1
26.144.6
0.13.7
--0.45.5

Multiple responses could be selected; Other sources included: distilled alkaline, water cooler, boiling, distributed water, not
applicable (n=3)
2
Multiple responses could be selected; Other sources included: parent's house to fill jugs, damaged new faucet,
water cooler, distribution site, not applicable (n=2)
3
Multiple responses could be selected; Other sources included: parents house, baby water, Culligan, water cooler, church,
husband from other

34

Table 15. Use of unfiltered water Flint municipal tap water by households
Frequency

% of HH

Projected HH

Weighted %

Unfiltered tap water use between April 2014 and October 2015 (n=175)1
Bathing/showering
171
97.7
23487
Washing dishes
164
93.7
22374
Brushing teeth
139
79.4
18404
Cooking
123
70.3
16937
Drinking
114
65.1
15213
Use with infant formula
12
6.9
1803
Other2
7
4.0
905
Unfiltered tap water use since October 2015 (n=167)3
Bathing/showering
150
89.8
20736
Washing dishes
137
82.0
18638
Brushing teeth
76
45.5
10043
Cooking
34
20.4
4609
Drinking
28
16.8
3411
Use with infant formula
7
4.2
940
Other4
9
5.4
1349

Weighted
95% CI

97.8
93.2
76.6
70.5
63.3
7.5
3.8

95.6100.0
88.897.5
66.087.3
61.080.0
53.473.3
3.012.1
1.1 6.4

90.9
81.7
44.0
20.2
15.0
4.1
5.9

86.9 94.9
74.389.1
35.2 52.9
13.0 27.4
8.621.3
0.8 7.4
2.2 9.6

Multiple responses could be selected; Missing (n=7)

Multiple responses could be selected; Other sources included: feeding pets (n=2), water plants (n=3), doing laundry (n=2)
3
Multiple responses could be selected; Missing (n=15)
4
Other sources included: laundry (n=7), watering plants, safe to shower
2

Table 16. Household difficulty obtaining bottled water, well water, or filtered water
Frequency
Difficulty obtaining water since October 2015 (n=182)1
Yes
32
No
149
Difficulties obtaining water (n=30)2
No transportation
18
Sites do not give out enough water
12
Disabled/homebound
8
Sites do not give out enough filters
8
Not enough money to purchase water
7
Not enough money to purchase filters
6
Store out of water
2
Store out of filters
0
Other3
9
Inconvenience4
5

% of
HH

Projected
HH

Weighted
%

Weighted
95% CI

17.6
81.9

4219
20660

16.9
82.7

10.823.0
76.788.7

60.0
40.0
26.7
26.7
23.3
20.0
6.7
0.0
30.0
55.6

2467
1564
1004
957
865
766
238
0
1208
684

62.3
39.5
25.4
24.1
21.8
19.3
6.0
0.0
30.5
56.7

42.482.1
18.560.4
6.943.8
6.541.8
5.138.6
3.335.4
0.014.5
--12.448.5
17.8-95.5

Dont know (n=1)

Responses from those that had difficulties; Missing (n=2)
3
Multiple sources could be selected; Other difficulties obtaining water included: store out of lead testers, location of
knowledge sites, medical, and not specified
4
Subset of other difficulties to obtaining water
2

35

Table 17. Location of water filters within households whose members used filtered water for drinking and
cooking
Frequency

% of HH

Projected
HH

Weighted
%

Weighted
95% CI

65
10
5
5
3
4

92.9
14.3
7.1
7.1
4.3
5.7

1140
1277
862
751
424
613

91.4
12.6
8.5
7.4
4.2
6.0

84.5-98.4
4.620.5
1.615.4
0.314.5
0.08.8
0.0-12.1

Location of filters (n=71)1

Kitchen sink
Bathroom sink
Pitcher filter
Shower head
Water valve
Other2
1

Multiple responses could be selected; Missing (n=16); Refused (n=1)

Other sources included: washing machine, basement tub, basement sink, bottled water, fridge, cannot use filter on the
faucet, landlord does not allow filter installation
2

Table 18. Household behavior change regarding use of water due to the Flint water crisis since October
2015

142
110
123
107

% of
HH
78.5
60.4
67.6
59.4

69

38.1

9212

37.0

29.944.2

80

44.7

10607

43.1

35.450.9

122

67.0

16964

67.9

60.675.2

55
61

30.2
33.7

7234
8565

29.0
34.4

21.236.7
26.042.9

Frequency
Reduced water usage (n=181)1
Decreased frequency of shower/bath (n=182)
Decreased duration of shower/bath (n=182)
Changed method of shower/bath (n=180)2
Decreased frequency of hand washing
(n=181)3
Decrease duration of hand washing (n=179)4
Used baby wipes/sanitizer for washing
(n=182)5
Bathe/shower outside of home (n=182)6
Bathe/shower with bottled water (n=181)7

Projected Weighted
HH
%
19449
78.2
14710
58.9
16741
67.0
14333
58.1

95% CI
73.682.8
52.365.5
61.472.6
52.363.8

Missing (n=1)
Missing (n=2); Dont know (n=1)
3
Missing (n=1); Dont know (n=1)
4
Missing (n=3); Dont know (n=1)
5
Dont know (n=1)
6
Dont know (n=1)
7
Missing (n=1)
2

36

Table 19. Type of information received by households regarding the Flint water crisis
Frequency

% of HH

Projected HH

91.2
88.4
78.5
77.3
55.8
52.5
48.6
47.0
37.6
0.6
5.0

22885
22303
19901
19570
14194
12755
12027
11948
9522
139
1163

Types of information received (n=181)1

Lead in Flint water
165
Bottled water/filter distribution
160
Filter instructions
142
Water testing resources
140
Nutrition
101
How to keep home lead-safe
95
Lead prevention for children
88
Physical health services
85
Behavioral health services
68
Did not receive information
1
2
Other
9

Weighted %

Weighted 95%
CI

92.0
89.7
80.0
78.7
57.1
51.3
48.4
48.1
38.3
0.6
4.7

87.996.2
81.597.9
71.388.8
70.187.3
45.069.2
41.760.9
38.957.8
37.458.7
28.947.7
0.01.7
1.18.2

Multiple responses could be selected; some responses were missing (n = 1)

Other sources included: freedom works, 2014 water report, attorney, fire hall, copper in water, letter, church, text message
from council woman, copper testing

Table 20. Flint water crisis household information sources, open-ended responses categorized

Sources of information (n=182)

Television
Neighbor/friend/family
Social media
Radio
Newspaper
Public Flier
Faith Based Organization
Internet
Health Professional
Text message
Other1
Community Engagement2
Mail2
School2

Frequency

% of HH

Projected HH

Weighted %

Weighted
95% CI

138
58
51
42
38
40
31
33
23
0
29
13
6
4

75.8
31.9
28.0
23.1
20.9
22.0
17.0
18.1
12.6
0.0
15.9
44.8
20.7
13.8

19129
8121
6781
6014
5177
5369
4583
4516
3379
0
3753
1547
722
565

76.6
32.5
27.1
24.1
20.7
21.5
18.3
18.1
13.5
0.0
15.0
41.2
19.2
15.1

68.085.1
24.740.3
18.336.0
17.031.2
13.927.5
12.730.3
12.424.3
12.024.1
7.219.8
--9.220.9
19.962.5
0.043.3
0.030.8

Open-ended responses were categorized: Other types of information mentioned included: lawyer, city employee, legal
meetings, news, work, multiple sources/everywhere (e.g., health professional, internet, social media, and fliers)
2
Subset of other sources of Flint water crisis information

37

Table 21. Most trusted source of information for households regarding the Flint water crisis

Trusted sources of information (n=182)

News media
Genesee County Health Department
Health professionals
Faith-based organizations
Social media
Aid organizations
School system
Don't know
Federal agencies
Genesee Health System
Michigan Dept. of Health and Human Services
City of Flint Water Department
Refused
Other1
Trusted self/Did not trust anyone2
None2
Not Government2
Friend/family2
Local/City Government2
Internet2

Frequency

% of
HH

Projected
HH

Weighted
%

Weighted
95% CI

48
16
14
12
10
9
8
7
3
2
2
2
1
47
16
11
5
4
2
2

26.5
8.8
7.7
6.6
5.5
5.0
4.4
3.9
1.7
1.1
1.1
1.1
0.6
26.0
34.0
23.4
10.6
8.5
4.3
4.3

6572
2313
2137
1590
1269
1213
1135
1087
357
327
286
223
167
6188
1926
1664
613
543
238
382

26.4
9.3
8.6
6.4
5.1
4.9
4.6
4.4
1.4
1.3
1.1
0.9
0.7
24.9
31.1
26.9
9.9
8.8
3.8
6.2

19.833.0
4.813.8
3.713.5
2.310.5
1.48.8
1.18.7
0.48.7
0.68.2
0.03.1
0.03.3
0.02.8
0.02.2
0.02.0
16.733.1
12.349.9
8.2-45.5
0.219.6
0.517.1
0.09.5
0.016.1

Open-ended responses were categorized; other sources that were not categorized (n=7) included: door to door helpers,
person who broke the news about crisis, lead abatement program, conference, Water defense team, self/world news, and
refused; missing (n=1)
2
Subset of other trusted sources

Table 22. Household Understanding of English

Frequency

% of HH

Projected HH

Weighted %

At least one household member does not understand English language (n=181)1
Yes
5
2.8
773
3.1
No
176
97.2
24091
96.9
1

Weighted
95% CI
0.2 6.0
94.099.8

Missing (n=1)

38

Table 23. Current greatest household needs at time of interview (May 2016)
Frequency
Greatest current household needs (n=178)1
Financial
60
Utilities2
10
Safe Water
48
Plumbing/Repair
27
Food
12
Filters
8
Health-related
8
3
Other
38
Nothing
17

% of HH

Projected
HH

Weighted
%

Weighted
95% CI

33.7
16.7
27.0
15.2
6.7
4.5
4.5
21.3
9.6

8224
1553
6745
3614
1717
1039
1136
4936
2372

33.6
18.9
27.5
14.7
7.0
4.2
4.6
20.1
9.7

26.440.7
7.430.4
19.835.2
8.021.5
3.210.9
0.87.7
1.6-7.7
12.328.0
4.814.6

Missing (n=4)
Subset of financial needs; Denominator is n = 60
3
Other includes: maintenance on structure of home, stability, just wants things to become stable, baby sitter, transportation,
home improvement, bed and dressers, yard work assistance, for those that lead us to straighten this out fast, humanely, follow
up, home repairs and sewage line repairs, summer, get out of Flint
2

39

Weighted Household Percentage

Figure 1. Household water sources for drinking and cooking at different time periods1
90
80
70
60
50
40
30
20
10
0

Bottled water from store

Filtered tap water
Unfiltered tap water
Home distributors
Distribution site
Before April 2014

April 2014 to October 2015

Current

Before April 2014, before the City of Flint, Michigan changed their municipal water supply source from Detroit-supplied
Lake Huron water to the Flint River; April 2014 to October 2015. After the City of Flint, Michigan changed their municipal
water supply source, but before residents of Flint, Michigan were advised not to drink the municipal water; Current, after
residents of Flint, Michigan were advised not to drink the municipal water

40

Appendices
Appendix A. Flint CASPER Questionnaire

41

42

Appendix B. Sampling frame and selected clusters in the City of Flint, with selected clusters circled in yellow

43

Appendix C. Public Health Informational Materials in Participant Gift Bag

Childhood Milestones: 2 Months to 5 Years - Watch Your Child for Signs of Lead Exposure as
They Grow
Health Care Coverage for People Impacted by Flint Water
Resources for Users of Flint Water
Lead in Flint Water
Fight Lead with Nutrition
Adding Phosphate to Flint Water
Installing a BRITA Filter
Installing a PUR filter
Lead Poisoning and Pregnant Mothers
Keeping Your Home Lead-Safe: Clean Your Aerators
Frequently Asked Questions about Fluoride, Bottled Water, and Oral Health
Keep your Pet Safe from Lead
Fight Lead with Healthy Food
Flush for Flint: Take These Steps to Flush Pipes and Aid in Flint Water System Recovery (in
English and Spanish)
Telephone list for Genesee County key departments
Meal programs available listed by Catholic Charities
Food bags announcement from Catholic Charities Center for Hope
Center for Hope Community Closet one-pager

44